Clinical
Pearls:
- Recommends
against routine episiotomy, advises restrictive use of episiotomy
- Warm compress
during pushing led to decreased incidence of third-degree and fourth-degree
lacerations.
- No single
birthing position helps in decreasing perineal lacerations.
- Suture
material used is absorbable synthetic ones with continuous suturing.
- Full
thickness external anal sphincter repair should be done end-to-end or overlap with
a single dose of antibiotics at the time of repair.
- Vaginal
delivery is an appropriate, safe option for women who have experienced severe
obstetric lacerations during previous pregnancies unless she had anal
incontinence, wound infection or repeat surgery.
- Does not
recommend the routine use of endoanal ultrasonography immediately after labor
to detect occult OASIS.
ACOG states
that 53% to 79% of patients will have some type of lacerations during vaginal
deliveries but most of them will not hamper the functional outcome.[1]
Most of these are first and second degree lacerations, but third and fourth
degree lacerations resulting in obstetric anal sphincter injuries (OASIS) can occur
in 11% of patients.
"The
previous bulletin did not focus on the broader concept of perineal lacerations
and anal sphincter injury. This was developed to be much more comprehensive and
to reaffirm to physicians that episiotomy is not recommended as routine part of
delivery." Said co-author Sara Cichowski. MD.
The bulletin
advises obstetrics practitioner against the routine use of episiotomy to
decrease perineal lacerations, instead take other measures to mitigate the
risk.
A review
involving 8 trials and 11,651 randomized women have concluded that warm
compress on the perineum during pushing is associated with decreased incidence
of perineal trauma.[2] (Level
A recommendation). Perineal massage, either during first stage or during the
second stage of labor, can decrease muscular resistance and reduce the
likelihood of laceration. Many other trials have confirmed the benefit of
perineal massage but ACOG did not recommend perineal support due to lack of sufficient
information and clinical methods.
Based on
clinical data ACOG recommends restrictive use of episiotomy as compared to
routine use. A systemic review[3]
found many benefits of restrictive use over routine use like severe perineal
trauma, less suturing and fewer healing complications. Both fared equal for severe
vaginal/perineal trauma, dyspareunia and urinary incontinence.
The bulletin
quotes "Current data and clinical opinion suggest that there are
insufficient objective evidence-based criteria to recommend episiotomy,
especially routine use of episiotomy, and that clinical judgment remains the
best guide for use of this procedure." [4]
National Episiotomy
rates have steadily decreased since 2006, when ACOG guidelines did not
recommend routine episiotomy. Data shows that in 2000, 33% of women received episiotomy
which has come down to 12% in 2012.
Data on
timing of giving episiotomy was sparse as also its benefit or harm in cases of
shoulder dystocia or operative vaginal delivery.
Clear
consensus also could not be reached on any single birthing position and delayed
pushing after full dilatation leading to decreased perineal lacerations and
episiotomy.
Minor tears
of anterior vaginal wall and labia can be left to heal by itself after achieving
hemostasis while periurethral, periclitoral and large labial laceration with
bleeding should be repaired. Clinicians are advised to use clinical judgement
when it comes to repair first- or second-degree lacerations due to lack of
evidence.
The choice
of suture material should be continuous absorbable synthetic ones, such as
polyglactin. Full thickness external anal sphincter repair should be done end-to-end
or overlap with a single dose of antibiotics at the time of repair. (Level A
recommendation).
ACOG also
states that majority of women with obstetric anal sphincter injuries (OASIS)
deliver vaginally in subsequent pregnancies. Cesarean delivery may be offered
to women who with history of OASIS if she experienced anal incontinence, wound
infections, repeat surgery or psychological trauma.
“Without
question, a vaginal delivery is an appropriate, safe option for women who have
experienced severe obstetric lacerations during previous pregnancies,” opined
Sara Cichowski, MD, who co-authored the new guidelines. “However, women who
have anal incontinence or who have suffered significant physical or emotional
trauma as a result of previous experiences may find that a cesarean delivery is
the right choice for them.”[5]
It also does
not recommend the routine use of endoanal ultrasonography immediately after
labor to detect occult OASIS, but advocates that a trained clinical research
fellow should examine the patient before the suturing perineal tear by the
attending physician. Detection of overt OASIS have a learning curve and
improves with education and training.
The bulletin
also provided recommendations for long term monitoring and pelvic floor exercises.
[1] http://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Ob-Gyns-Can-Prevent-and-Manage-Obstetric-Lacerations
[2] http://www.ncbi.nlm.nih.gov/pubmed/22161407
[3] http://www.ncbi.nlm.nih.gov/pubmed/19160176
[4] http://journals.lww.com/greenjournal/Abstract/2016/07000/Practice_Bulletin_No__165___Prevention_and.46.aspx
[5] http://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Ob-Gyns-Can-Prevent-and-Manage-Obstetric-Lacerations
